Final report on Alaska Airlines Flight 1282 in-flight exit door plug separation

https://www.ntsb.gov:443/investigations/Pages/DCA24MA063.aspx

by starkparker • 1 year ago

167 185 1 year ago

The accident happened because a piece on the airplane wasn’t put back on the right way. The company that made the plane didn’t teach the workers well enough or check their work carefully. Also, the people in charge of making sure planes are safe didn’t do a good job checking on things.

heywoods• 1 year ago

What Boeing plant was the aircraft assembled at where this failure occurred?

kayfox• 1 year ago

As with all but the first few 737s, it was assembled at Renton. The door plug was installed in Wichita by Spirit Aerosystems and there were issues with rivets in the surrounding structure that Spirit removed the plug to correct in Renton.

As a result of this Boeing is now refusing to sign off on fuselages with defects found at Spirit to be transported to Renton. And also Boeing will be buying back Spirit, which had been spun out of Boeing by the McDonall-Douglass management that took over Boeing when McDonall-Douglass bought Boeing with Boeings own money.

umeshunni• 1 year ago

The fuselage is made by Spirit AeroSystems in Wichita, KS:

https://www.npr.org/2024/06/04/nx-s1-4983722/inside-spirit-a...

The 737 assembly happens in Renton, WA

bboygravity• 1 year ago

And the whistleblower trying to warn people about this and other issues was potentially executed by the company.

tptacek5• 1 year ago

No he wasn't, and he wasn't.

BolexNOLA5• 1 year ago

I see this conspiracy theory hasn’t died yet

ryandrake3• 1 year ago

At the risk of overgeneralizing, more and more in modern life it feels as though we are all surrounded by people who are supposed to do their jobs right who don't, and people who are supposed to inspect their work who aren't inspecting, and people who are supposed to check the inspection process who aren't checking, and a legislative body who's supposed to regulate all the checking and double checking who aren't doing anything at all!

It's like vast swaths of people are just fooling around, collecting a paycheck, but aren't doing what they're supposed to be doing, and we're all just miraculously surviving our day-to-day because a bunch of denominators are very large numbers!

pishpash• 1 year ago

No, because some people still care and clean up enough after the slackers. The slackers also realize this and slack just enough for nothing major to happen often.

HeyLaughingBoy3• 1 year ago

I have worked in the medical devices industry as a software engineer for about 20 years at this point. As you would expect, it's a very process-heavy field. I've generally worked with careful, competent people who want to do a good job and process goes a long way towards facilitating that.

Every time I think about process though, I remember an editorial I read a long time ago about an engineer's experience in the aviation industry. He wasn't too thrilled about process. Instead, in his own words, "we were motivated by a very sincere desire to not kill anyone.

tiahura• 1 year ago

The counter-culture successfully demonized concepts like duty, personal accountability, and shame. A boy scout was to be mocked.

renewiltord• 1 year ago

It’s because we are very good at getting smart people into high comp jobs so all these low remuneration jobs are pretty much idiots.

If they can avoid weed long enough to pass the drug tests, they’ll be playing Candy Crush on their phone when inspecting.

They just don’t have the mental horsepower. Like being upset a jellyfish didn’t discover calculus.

Patio11 calls this The Sort. I thought it was good name.

mschuster91• 1 year ago

pay peanuts, get monkeys.

when you pay utter shit but the c-level earns many 100x the salary of the workers, of course they don't give a fuck.

visarga• 1 year ago

At the risk of overgeneralizing, more and more in modern life it feels as though we are all surrounded by people who are supposed to do their jobs right who don't

Meta observation - human society works by abstraction - leaky, and functional - not genuine understanding. Searle was wrong. There is no genuine understanding, only a web of abstractions that sometimes break.

metabagel3• 1 year ago

In general, people do what the organization providing their paycheck asks them to do. If their manager tells them to cut corners, they'll likely cut corners.

Some people are opposed to bureaucracy and will tend to try to undermine processes which are designed to prevent errors in production and execution. Organizational culture needs to be established and maintained, which aligns everyone toward the processes needed to maintain required standards.

aboodman• 1 year ago

At the end of the day people have to care about their job, for a reason bigger than getting a paycheck. Society can coast for awhile when people don't care but things eventually break down.

You can add process but the people running the process have to care. You can add regulation, but then the regulators have to care.

At the end of the day people have to care. And it really has to be everyone, because if one group cares and another doesn't, the one that cares will soon get disillusioned.

Caring alone is not sufficient. You do need process to catch mistakes. But process alone is also not sufficient.

pulse72• 1 year ago

"What We Found

We determined that the probable cause of this accident was the in-flight separation of the left MED plug due to Boeing’s failure to provide adequate training, guidance, and oversight necessary to ensure that manufacturing personnel could consistently and correctly comply with its parts removal process, which was intended to document and ensure that the securing bolts and hardware that were removed to facilitate rework during the manufacturing process were properly reinstalled. Contributing to the accident was the FAA’s ineffective compliance enforcement surveillance and audit planning activities, which failed to adequately identify and ensure that Boeing addressed the repetitive and systemic nonconformance issues associated with its parts removal process."

pulse72• 1 year ago

Somehow Boeing is happening to the whole IT industry at the moment where AI is forced upon programmers instead of "properly developing software" ...

thewebguyd• 1 year ago

It's a byproduct of unchecked capitalism. This behavior will continue as long as there are no real consequences for those in charge.

nyarlathotep_2• 1 year ago

My experience is somewhat limited professionally in software (just under a decade), but with very few exceptions I've seen little in terms of genuine professionalism as it pertains to anything that could be called "engineering."

Most design/implementation decisions were basically (or literally) equivalent to "we use Kubernetes cause we've already got a lot of existing Terrraform for it", or "we have React developers." I know real professionalism and maybe even "engineering" practice exists somewhere (I mean it has to, for something rigorously proven, right?), but I've not personally experienced it; I've seen this everywhere, as a consultant and employee, both in the public and private sector.

The number of times I've been on meetings or similar where there's tradeoffs backed by quantifiable data was a handful, at best, so the AI trend makes perfect sense to me.

I really don't imagine with something like Boeing where there's a far higher burden of proof there's discussions around, like, some equivalent subjective thingy like "code smells" or "anti-patterns."

thomascountz• 1 year ago

We determined that the probable cause of this accident was the in-flight separation of the left MED plug due to Boeing’s failure to provide adequate training, guidance, and oversight necessary to ensure that manufacturing personnel could consistently and correctly comply with its parts removal process, which was intended to document and ensure that the securing bolts and hardware that were removed to facilitate rework during the manufacturing process were properly reinstalled.

A bit OT, but what a gorgeous whale of a sentence! As always, the literary prowess of NTSB writers does not disappoint.

pj_mukh• 1 year ago

Looking forward to the length of the sentence the NTSB uses for Air India flight 171. Gonna be a doozy

JSteph22• 1 year ago

Wouldn't it be the Indian authorities who issue a report?

CGMthrowaway3• 1 year ago

AKA Boeing did not train, guide or oversee its people well → Workers skipped the process meant to keep track of bolts and hardware → The bolts for the mid-exit door were never put back → At 14K feet, the door blew free.

gtech12• 1 year ago

Physics question: why do I know (maybe wrongly) that in flight the doors are sealed shut by the difference in pressure ? And if so, why did it not work in this case ?

0rzech8• 1 year ago

At school (Polish class in Poland) we were always taught to prefer complex and compound sentences over simple ones, because it's more elegant and speaks well the speaker/writer.

tuukkah4• 1 year ago

Same happening in Hispanic school systems could explain the sentences in some of the Spanish Wikipedia articles.

ecb_penguin• 1 year ago

It doesn't, though. It's pretentious and educated people will see through it. If the goal is to inform, then you should do the opposite.

SilasX3• 1 year ago

Well that’s one source (of many) where the problem is coming from.

Telemakhos• 1 year ago

This sentence isn't written for elegance but for meaning. The formal cause of the accident was the mechanical separation, but that happened for a reason, either mechanical failure (which means a failure in the engineering of the aircraft, which would have to be remedied by new engineering processes) or an assembly failure (which would have to be remedied by new assembly processes). In one sentence, the author drills down to exactly what went wrong that enabled the accident to happen. Identifying that is the first step to remedying it.

yongjik• 1 year ago

Could've been worse. In Korean schools they somehow find the worst, most meandering and pointless examples of English prose and shove them at poor students at exam time to test their "English comprehension" skills, when any reasonable native speaker would've said "Who the fuck writes like this?"

tliltocatl• 1 year ago

That's true for fusional languages. English isn't one.

ryandrake3• 1 year ago

Reading aviation-related NTSB final reports is kind of a hobby of mine, and I must say, the NTSB is generally a treasure! Sure, you can find issues with some of their investigations, roads they might not have probed down as far as they could, but their culture of root causing and transparently reporting should be emulated across the government. I really hope they don't fall victim to the casual, random destruction our current administration is inflicting on broad swaths of the government.

frumplestlatz5• 1 year ago

The current aims of the executive branch are neither casual nor random, and I doubt the NTSB is in their crosshairs.

The goals are both obvious and specific; it’s a culture war being fought at the funding level.

lemoncucumber• 1 year ago

Reading NTSB reports themselves isn't for me, but I really enjoy reading this blog that does excellent write-ups of past plane crashes. It's really well written, easy to follow, and fascinating: https://admiralcloudberg.medium.com

JoshTriplett2• 1 year ago

Also, I really appreciate the way they put blame where it belongs. They don't say "manufacturing personnel failed to ...", they say "Boeing failed to provide adequate training, guidance, and oversight necessary to ensure that manufacturing personnel could consistently and correctly ...".

wat10000• 1 year ago

They know their business. The goal is safety, not punishment. Blaming workers is great if you're after revenge or a scapegoat, but generally doesn't improve safety.

mrandish2• 1 year ago

Agreed about properly assigning the root cause to inadequate training but the sentence was unnecessarily complex in not making the first order cause clear until the end. I'd prefer stating up front that the first order cause was "securing bolts and hardware that were removed to facilitate rework" were not reinstalled - and then stating the root cause leading to that being inadequate training.

In the context of a summary I just expect the core sentence to take events in order from the headline failure ("in-flight exit door plug separation") and then work back to the root cause.

tialaramex2• 1 year ago

Right, Alaska didn't buy an aeroplane from "manufacturing personnel" they bought it from Boeing. If Boeing don't want to sell aeroplanes that's cool, bye-bye Boeing, but if they want to sell aeroplanes then it's their responsibility to ensure those planes are safe and it cannot somehow be a transferable responsibility.

megablast• 1 year ago

They don't say "manufacturing personnel failed to ...", they say "Boeing failed to provide adequate training, guidance, and oversight necessary to ensure that manufacturing personnel could consistently and correctly ...".

Doesn't this mean it should happen a lot more?

SoftTalker2• 1 year ago

These investigations are about identifying root causes, not assigning blame.

dlcarrier• 1 year ago

My favorite NTSB-ism is "controlled flight into terrain", which means "crashed". This is as opposed to "uncontrolled flight into terrain", which means "fell from the sky".

hectormalot• 1 year ago

I think CFIT is appropriate. There’s loads of cases where pilots flew into a mountain due to lack of environmental awareness. Here’s a bizarre example: https://admiralcloudberg.medium.com/lost-and-confused-the-cr...

scoot3• 1 year ago

Both result in a crash – the first due to pilot error, the second due to mechanical failure.

FL410• 1 year ago

It’s a bit more nuanced than that. CFIT is intended to classify accidents where the aircraft itself was not causal. In any other case, it is assumed that there were mechanical or other aircraft-related factors that were contributory or causal.

ghushn32• 1 year ago

It seems pretty clearly describing a state + an outcome.

"(pilot control state) flight into (outcome of flight)"

One of those pieces of jargon that feels silly until you go, "Oh, actually, this makes a lot of sense when you deconstruct it."

gcau• 1 year ago

It's a legitimate distinction, "they were in control" and "they weren't in control". If the pilots are on a collision course with a mountain, but are happily sitting there thinking they're going the other way, there's nothing wrong with the plane, and the pilots are in control of the plane. In contrast to a horizontal stabilizer failure, where the pilots aren't in control, and instead say their goodbyes for the cockpit voice recording.

scoot3• 1 year ago

We determined that the probable cause of this accident was the in-flight separation of the left MED plug

I find this very strangely worded. It was an "incident", not an "accident"; and "the in-flight separation of the left MED plug" was the incident, not the cause of a non-existent accident.

The actual cause of the incident (as determined by the NTSB) is what follows all that unnecessary verbage.

tuukkah4• 1 year ago

How about like this? "We determined the accident's probable cause: The in-flight separation of the left MED plug happened because Boeing had failed to provide adequate training, guidance, and oversight. These would have been necessary to ensure that manufacturing personnel could consistently and correctly comply with Boeing's parts removal process. The securing bolts and hardware had been removed during manufacturing to facilitate rework, and the process intended to document and ensure proper reinstallation."

colechristensen• 1 year ago

The NTSB remains very good at its job and should serve as a model for government. A beacon of hope.

aredox• 1 year ago

Don't worry, as a consequence , Boeing is being awarded contract after contract by the current administration.

hughes• 1 year ago

Part of me wonders if the plug could be designed such that it's obvious when the bolts are missing. Would this have happened if it were impossible to assemble without them, or if it were easy to verify their presence?

Maybe it doesn't matter if a better design is possible - if adequate procedures exist and weren't followed, and oversight fails to catch instances of that, then anything could go wrong.

burnt-resistor5• 1 year ago

The general principle would be making other parts with interference fit such that it or they visibly do not align without properly tightening/attaching parts below/about them. For example, the door plug should not sit in the correct position unless door plug bolts are all tightened and untightened door plug bolts shouldn't allow installing other parts like trim pieces to be flush.

Every critical step should be as "idiot-proof" as possible, until better idiots are created who hammer structural parts into position to meet management-mandated arbitrary deadlines.

codedokode2• 1 year ago

I don't know if you were joking about the hammer or referring to a Russian assembly worker who used a hammer to install accelerometers in a rocket into a wrong position which caused it to attempt to fly downwards (no people were injured) [1].

[1] https://en.wikipedia.org/wiki/Proton-M#Notable_launch_failur...

tialaramex2• 1 year ago

Note that you can solve that last problem but you need to think outside the box.

Hammering structural parts which don't want to go is hard work and if your workers have union protection you can bet they'll say "No". So what you need are strong union protections so that they feel able to say "No" when asked to do unreasonable things. Does that mean they're going to be a little harder to manage? Maybe, but mostly it means "Rule by fear" doesn't work and leadership might need to learn to inspire not threaten.

Union protections help in one place you're already familiar with. If your pilot says "No, I don't like those clouds at all" and won't fly, the airline can't fire them for that. That's their judgement, if you fire pilots who you feel aren't risking passengers necks to make the line go up you're not going to have any pilots at all.

Historically it helped for traffic control, but that's OK our old friend, Cowboy Actor and Friend of the Working Billionaire, Ronald Reagan smashed that, so now traffic control has the shocking poor working conditions Corporate America loves.

toast02• 1 year ago

It sounds like Boeing is doing a design enhancement. I found this article [1] that describes features for the bolts as:

The fix also includes adding lanyards atop the door-plug bolts to “permanently secure the bolts to the plug” and “provide a visual indication”, says Crookshanks. “They’ll hang there and be visible to a mechanic that had taken the bolts out.”

[1] https://www.flightglobal.com/safety/details-emerge-about-boe...

gavinsyancey• 1 year ago

Once you complete the certification of Boeing Commercial Airplanes’ design enhancement for ensuring the complete closure of Boeing 737 mid exit door (MED) plugs following opening or removal, issue an airworthiness directive to require that all in-service MED plug-equipped airplanes be retrofitted with the design enhancement. (A-25-15)

It sounds like Boeing is currently working on designing and certifying a design enhancement to the MED plug to make it obvious if one is not closed properly. Not sure where to find the details on it though.

lyrrad• 1 year ago

I believe that's what this directive is for:

"To the Federal Aviation Administration:" " Once you complete the certification of Boeing Commercial Airplanes’ design enhancement for ensuring the complete closure of Boeing 737 mid exit door (MED) plugs following opening or removal, issue an airworthiness directive to require that all in-service MED plug-equipped airplanes be retrofitted with the design enhancement. (A-25-15)"

This article: https://aerospaceglobalnews.com/news/boeing-completes-design..., suggests that the design enhancement will add "secondary retention devices" that "prevent installation of the cabin sidewall panels unless they are properly engaged." The article indicates that the existing bolts will also get lanyards that will "'permanently secure the bolts to the plug' and provide a visual indication' of whether they have been installed correctly."

Apparently, if only one of the four bolts was installed, it may have been sufficient to prevent the accident, according to: https://www.nytimes.com/2025/06/24/us/politics/boeing-alaska...

xenadu024• 1 year ago

The plugs are designed to be semi-permanent because they are only for emergency exits on certain high-capacity seat layouts not used by most US airlines (or any airline that has first class seats I believe). When you have more seats you need more exits.

Given their nature the original intent was probably that they were secured at the factory and never touched. But because they are convenient for access during maintenance/inspection they get used more often.

This issue, the oxygen mask, and the child restraint issue are the NTSB doing the proper "what if things had been slightly different" calculation.

Airline maintenance removes and reinstalls these doors. They could accidentally commit the same error so Boeing should change the design such that the door will not stay in-place when the bolts are removed. Could be as simple as springs that force the plug open without the bolts. If the door won't stay closed without the bolts like a light switch it will be forced to clearly show when it is safe vs not.

Child restraints were mentioned partially because if a lap child had been in that row they'd have been sucked out by the decompression and free-fallen 14000 ft. It was entirely luck that it didn't happen.

Oxygen masks mentioned because the pilots had some trouble getting them on in a timely manner. If the incident had been sudden onset of thick toxic smoke one or both could have passed out before getting the mask on and oxygen flowing. That's like a fire extinguisher with a complicated pin mechanism. Adrenaline dump during emergencies ruins fine motor control, critical thinking, etc. The worst possible time to have something be fiddly and complicated. You want it to be muscle memory. So trivial a 5 year old child could do it without being taught.

And the CVR issue is just the NTSB mentioning that yet again for like the 100th time the CVR circuit breaker was not pulled so we lost the recording and any potential learnings to be had from examining them. This is a problem that just keeps happening over and over. Because it relies on pilots, after a huge emergency, to remember to pull a circuit breaker when they have a thousand far more important things to worry about (not to mention coming down from the adrenaline high) and the thing only keeps the last two hours... which was a standard set when they were continuous loops of wire before the switch to magnetic tape. All the new ones are little computers and flash chips.

potato37328422• 1 year ago

. If the incident had been sudden onset of thick toxic smoke

Pinpoint "seems reasonable" changes like that without regard for the whole system of interactions are what sank Thresher.

The "sudden onset of thick toxic smoke" is rare. It's either not that toxic or the onset isn't that sudden. You can't just design the system based on assumptions of needing to cover a rare corner case without taking a look at the whole general thing and the frequency of various anomalies and crunching the numbers to see if you're not actually making it worse. I agree that the masks should be simple and reflexive but you absolutely could compromise the whole system if you prioritize reflexive over other attributes without actually taking a full stack look at the tradeoffs in all areas. Aircraft manufactures employ people to think about this stuff and they're frequently why "seems reasonable" changes don't get made.

mrpippy• 1 year ago

Given their nature the original intent was probably that they were secured at the factory and never touched

Specifically in this case, that factory being Spirit Aerosystems in Wichita where the 737 fuselage is manufactured. Part of the problem here is that Boeing in Renton didn't have processes for removing the MED when necessary on the final assembly line (in this case to rework rivets near the door). Without processes, there was one senior guy on the door team who taught himself how to do it, this was only needed a few times a year, but he was on vacation when this airframe needed the MED removed. Someone else did it (the NTSB couldn't determine who), the work wasn't tracked, and a separate team (the team literally sealing it up so it could be moved outside) put the MED back in but didn't install the bolts (which were gone).

toast02• 1 year ago

Because it relies on pilots, after a huge emergency, to remember to pull a circuit breaker when they have a thousand far more important things to worry about (not to mention coming down from the adrenaline high) and the thing only keeps the last two hours...

Clearly, relying on people to do this after the incident doesn't work, but.. shouldn't this be in like the post-incident checklist?

Either a checklist for the pilot, or an incident manager... there's got to be a list of things to do, and pull the breaker on the recorder isn't going to be high on the list, but I would think it would be on it.

ratdoctor• 1 year ago

There are a couple of typos on the page

dDevelop guidance for Federal Aviation Administration managers and inspectors
<strike>P</strike>rovide Federal Aviation Administration managers

scoot3• 1 year ago

Fortunately neither of these is likely to cause an aviation incident or accident.

mmwelt• 1 year ago

Obviously, such mistakes have no bearing on the content of the report. However, there are usually certain expectations of a formal report from an official government bureau, including a standard of presentation.

tonymet• 1 year ago

i think proximate/ultimate breakdown would be more readable here. Proximate cause: poor installation. Ultimate cause: bad docs and quality control.

callamdelaney• 1 year ago

Having been on an air crash investigation kind of vibe since the Air India accident, I have conflicting opinions on boeing.

On one hand, their quality control, engineering etc has been declining, not to mention the suspicious deaths of whistleblowers..

But on the other, the fact that each pilot can see and feel immediately what inputs the other is applying is such a huge advantage compared to airbus’ fly by wire.

There are at least 3 accidents on airbus planes which can effectively be attributed to dual input. Loss of situational awareness, highly technical changes in the way the aircraft controls (why would this ever be a good idea), given certain circumstances.

Imagine dying because of the different between ‘pull down’ and ‘push down’. On a boeing, when the captain pushes the nose down, you see immediately what he means. On an airbus, you’re dead by the time the captains input override is acknowledged.

There are definitely pro’s to the airbus system but why cant we add input feedback?

xenadu024• 1 year ago

FWIW Airbus has tested a force-feedback side stick. Why they don't already offer it as an option I do not know. Maybe they are calmer now but for decades they took the attitude that "We built an un-crashable airplane because we are smarter than you" and took any criticism as a personal attack.

If you're curious the 757, 767, 777, and 787 are all fly by wire but use both physical linkage under the deck and force-feedback servos to transmit control surface feel back to the pilots. But they also have torque tubes that can be overpowered and ... shocker... in a dual input situation they do the same as Airbus: average the inputs. But at least you have to really yank on the controls to make that happen.

anonymars• 1 year ago

I suspect this brief lecture (2 parts) on automation dependency will be right up your alley: https://www.youtube.com/watch?v=WITLR_qSPXk

whycome• 1 year ago

What's the latest on Air India? Fuel Switches were last I saw and if it means one pilot is able to disengage unilaterally, it kind of falls into the same area about design philosophy (I think they are located on diff areas for diff planes).

inejge• 1 year ago

But on the other, the fact that each pilot can see and feel immediately what inputs the other is applying is such a huge advantage compared to airbus’ fly by wire.

Confusion is still possible on Boeing aircraft[1] (the incident happened with an Air France 777 in 2022. AvHerald has more direct quotes from the official report.)

[1] https://www.flightglobal.com/safety/opposing-dual-inputs-con...

xenadu024• 1 year ago

Remember:

McDonald-Douglass management (of the Jack Welch school) took over at Boeing post-merger. Widgets are widgets and people are just another kind of widget. Job #1 was to screw labor and engineering out of money so that money could go into management's pocket (in the name of shareholders but screwing shareholders is also part of the deal).

They moved HQ away from Seattle specifically so engineers and production personnel couldn't stomp into management's offices and yell at them about safety or anything else.

Then they started outsourcing whatever they could to remove as many people as possible from Boeing's union contracts, corporate benefits, etc and replace those highly paid professionals with the cheapest bodies they could find. After all - the Jack Welch school of thought is the Important People (managers) just need to break down the process (any process) into enough small simple steps that a monkey could do it. Then you could hire the cheapest possible unskilled labor and pay them peanuts but it wouldn't matter because a widget is a widget. People are just widgets. Swap an expensive widget for a cheap one. Duh.

This first came home to roost on the 787 project. Boeing outsourced vast amounts of the project which came back to bite them in the form of delays. They were supposed to start flying in August 2007 and deliver to customers in 2008 but horrible subcontractor designs, rework, unfinished work, etc led to huge assemblies arriving in Everett in a shambles. Repeated delays meant the first aircraft wasn't delivered until September 2011 a full three years behind schedule. Boeing had to buy back in-house a number of their contractors to even make that happen.

That was promptly followed by battery fires that grounded the entire 787 fleet for part of 2013. The first grounding of a transport category airliner since 1979.

Did I mention the 787 had quality problems from 2019 until 2023 (some say ongoing problems even up to today), resulting in missing fasteners (!!!), improperly installed fuel lines, and other issues. For some time they not only had to halt deliveries they had to halt production.

Does any of this sound familiar? It should because the exact same issues plagued the 737 MAX from the start! Rushed engineering without internal peer review or proper consideration (single data source). Rosy assumptions about how pilots would handle various emergencies. Outsourcing to screw labor. Terrible mis-management. Incompetent contractors. Complete lack of process control inside Boeing and complete lack of shits given by Boeing management at any level. Callus lack of regard for any human anywhere (passengers, pilots, airline employees, their own employees)... Boeing knew there was a problem with MCAS and their published guidance wasn't the final word but lied to Ethiopian airlines about it (whos pilots asked some excellent pointed questions). Those lies likely directly leading to the second hull loss event.

Also the same expensive "solutions". Huge re-certification of their process and self-certification procedures. Buying back in-house contractors they originally spun out to cut benefits.

And the 737 MAX itself being a terrible idea, cancelling the clean-sheet A32x competitor in favor of more duct tape and bailing wire on a design with way too many manual reversion modes. On the 787 alternate gear extension is a button press. Dual generator failure auto-starts the APU and deploys the RAT. Electric re-routes automatically. On the 737? LOL nope. All manual. Manual gear means copilot has to stand up, get behind their chair, open a floor panel, then pull three separate cables to about chest-height. Bird ingestion dual engine failure at 1500ft? Not a chance that's happening. But hey according to Boeing's new CEO that is all fine, we aren't doing "the new airplane".

The amount of value destruction of Boeing as a company, Boeing's market share, Boeing's brand, and ultimately Boeing's share price as a result of management trying to screw over labor and taking a short-term view of everything is jaw-dropping.

Nothing has changed at Boeing. They got caught with their hand in the cookie jar. They are doing the absolute bare minimum to make everyone shut up about it and get back to the status quo. How many more times are they going to lose self-certification status? How many more times will they be told to overhaul internal procedures and come up with yet another System to make sure they follow their own rules. All the while management keeps rewarding themselves for outsourcing, cutting pay/benefits, and business as usual. How long will this supposed new quality attitude last? Anyone gonna get promoted to SVP because we didn't have anymore accidents? Gotta weigh that against the exec who outsourced production of control surfaces so we could lay off 500 machinists at $150/hr fully loaded so a contractor can hire $25/hr smucks to do the work thus saving us millions. Gee wonder who's gonna get that promotion after all?

omgJustTest4• 1 year ago

long story short:

1. boeing and spirit both work on planes

2. damaged rivets discovered and lots of back and forth to get them repaired. boeing does the doors and spirit does the rivets.

3. rework on rivets needed door plug to be removed, someone at boeing (who is not onsite) sees that the door plug needs to be removed, escalates this request but notes that work must wait for the next week because the only door person who is qualified to remove plugs is on leave.

4. door manager - on the day of the plug removal - de-escalates the door plug removal request. later that day the door manager, door master and three door crew enter area near the fuselage & door plug - correct documentation of removal not generated and none of them were trained to remove door plug. No one knows who removed the plug.

5. a boeing technician moves a stand that has what he believed to be a door plug bolt on top of it. he "strapped it and let it hang" to the fuselage.

6. Spirit indicates plug was removed and reworks rivets

7. No one checks the door plug was reinstalled correctly

morninglight• 1 year ago

Boeing also had a rivet problem on Japan Air Lines Flight 123 in 1985 and 520 people died.

https://en.wikipedia.org/wiki/Japan_Air_Lines_Flight_123

hbcondo714• 1 year ago

The crash is the deadliest single-aircraft accident in aviation history…caused by a faulty repair by Boeing technicians

Extremely sad to learn this. It could have been prevented.

tomcam2• 1 year ago

Damn son, thanks

omgJustTest4• 1 year ago

I really love reading NTSB and Coast Guard break-downs... a lot of very interesting engineering!

getnormality• 1 year ago

Also, Boeing spun off Spirit in 2005 to juice its own profit margins, so the poor coordination between these two entities is ultimately Boeing's poor judgment. And more specifically that of Harry Stonecipher, perhaps the worst American CEO this side of Jack Welch.

dmix• 1 year ago

A benefit of being a golden child business to the US government is you don’t have to worry about economic consequences like a normal business. They’ll still make money off gov contracts and the “local jobs” monopoly system that congress protects like the mob.

burnt-resistor5• 1 year ago

Yep. And it's all fruit of the MD management takeover in '94.

https://www.economist.com/news/2014/11/17/the-trouble-with-m...

omgJustTest4• 1 year ago

Full NTSB report https://www.ntsb.gov/investigations/AccidentReports/Reports/...

mannyv• 1 year ago

4. Someone knows who removed the plug, but they're not about to fess up to it because they totally fucked up.

comrade1234• 1 year ago

So many Boeing shills posting here... who are you trying to convince on hacker news? No one here is influencing airlines or states on planes to buy.

Boeing is dead.

dtgriscom• 1 year ago

That's a bit extreme.

golergka• 1 year ago

dDevelop guidance

Good to know it was written by a human and not an LLM.

Final report on Alaska Airlines Flight 1282 in-flight exit door plug separation

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